Week4 - Men's & Women's Health

Question 1

Consultations Regarding Menstrual Problems

History
Additional Questions
Investigations

Answer 1

1. ) History - ask about last normal menstrual period,
   - regular? painful? heavy? prolonged?
   - associated symptoms: e.g. abdominal pain, fever, vaginal discharge, dysparaeunia
   - aggravating factors: e.g. exercise, intercourse
2. ) Additional Questions
   - previous pregnancies, risk of current pregnancy,
   - risk factors of ectopic: PID, endometriosis, IVF, IUD, POP
   - sexual history, PMH, DH
3. ) Investigations
   - pregnancy test: always check
   - infection screen: chlamydia and gonorrhoea
   - blood test: FBC, clotting, TFT, FSH/LH

Question 2

Causes of Abnormal Uterine Bleeding

Inter-Menstrual Bleeding
Post-Coital Bleeding
Breakthrough Bleeding

Answer 2

1. ) Inter-Menstrual Bleeding - between periods
   - pregnancy: miscarriage, ectopic pregnancy
   - physiological: vaginal spotting (time of ovulation)
   - cervical/endometrial polyps, ectropion, fibroids,
   - infection: vaginitis, chlamydia, gonorrhoea
   - cancer: vaginal, cervical, endometrial
   - iatrogenic: tamoxifen, ineffective contraceptive pills
2. ) Post-Coital Bleeding - immediately after sex
   - cervical/endometrial polyps, cervical ectropion
   - vaginal atrophic change, vaginal/cervical cancer
   - STIs (especially chlamydia)
   - no specific cause is found in 50% of women
3. ) Breakthrough Bleeding - while on contraception
   - common when any new method has started
   - more common w/ progesterone only and in smokers
   - often settles without any intervention
   - must still rule out pregnancy or underlying infection

Question 3

4 different classifications of abnormal uterine bleeding

Acute
Chronic
Structural Causes (PALM)
Non-structural Causes (COEIN)

Answer 3

1. ) Acute AUB - heavy bleeding of sufficient quantity to require immediate clinical intervention to stop further blood loss
2. ) Chronic AUB - bleeding of abnormal volume, duration, regularity, or frequency that has been present for most of the previous 6 months
3. ) Structural Causes - PALM
   - Polyps
   - Adenomyosis (lining breaks through myometrium)
   - Leiomyoma (fibroids)
   - Malignancy (or hyperplasia)
4. ) Non-structural Causes - COEIN
   - Coagulopathy
   - Ovulatory Dysfunction (inc thyroid)
   - Endometrial
   - Iatrogenic
   - Not yet classified (dysfunctional uterine bleeding)

Question 4

Menorrhagia

Clinical Features
Potential Causes
Investigations
Management

Answer 4

1. ) Clinical Features
   - excessive blood loss every cycle interfering w/ QoL
   - classified as >80mL or duration > 7 days
2. ) Potential Causes
   - dysfunctional uterine bleeding in 50% of people
   - uterine fibroids, endometriosis, PID
   - coagulation disorders or anticoagulant treatment
   - hypothyroidism, diabetes, liver/kidney disease
   - chemotherapy
3. ) Investigations
   - FBC to rule out iron deficiency anaemia
   - physical examination if also has other symptoms e.g. IMB, pelvic pain, pressure symptoms
4. ) Management - if not fibroids or adenomyosis
   - levonorgestrel-IUS is first line treatment (Mirena coil)
   - non-hormonal drugs: NSAIDs, tranexamic acid,
   - hormonal drugs: COCP, or POP

Question 5

Dysmenorrhoea

Primary Dysmenorrhoea
Secondary Dysmenorrhoea
Causes of Secondary Dysmenorrhoea
Management

Answer 5

1. ) Primary - occurs 6-12 months after menarche
   - normal pelvic examination (no pelvic pathology)
   - lower abdominal pain shortly before menstruation, lasting up to 72 hours, and then begins to improve
   - additional symptoms: headaches, N/V, diarrhoea, fatigue, dizziness, low back pain
2. ) Secondary - after several years of painless periods
   - pain may persist after menstruation finishes or be exacerbated by menstruation
   - pelvic exam may be abnormal or normal
3. ) Causes of Secondary Dysmenorrhoea
   - endometriosis/adenomyosis: chronic pelvic pain, menorrhagia, deep dyspareunia
   - fibroids: abdominal pain, menorrhagia, pelvic mass
   - PID: abdominal pain, AUB, dyspareunia, fever
   - ovarian/cervical cancer, IUD insertion (3-6 months)
4. ) Management
   - primary: NSAIDs, hormonal contraception, local application of heat, TENS (nerve stimulation), symptoms should resolve in 3-6 months, if not refer
   - secondary: refer to secondary care

Question 6

5 causes of secondary amenorrhoea

Physiological
Endocrine
HPG Axis
PCOS
Anatomical

Answer 6

1.) Physiological Causes - pregnancy and menopause

2. ) Endocrine - thyroid diseases and hyperprolactinemia
   - menstrual abnormalities in hyper and hypothyroidism
   - hyperprolactinemia causes androgen excess
3. ) Hypothalamic and Pituitary Disease - abnormal GnRH secretion -> no LH surge -> anovulation -> low oestrogen
   - e.g. prolactinoma, pituitary necrosis
4. ) Polycystic Ovarian Syndrome (PCOS)
   - hyperandrogenism and chronic anovulation
   - menstrual irregularity + androgen excess + obesity
5. ) Anatomical Causes
   - scarring due to cervical stenosis or intrauterine adhesions (asherman syndrome)
   - primary ovarian insufficiency (POI) causing premature menopause

Question 7

Red flags for gynaecological cancers

Endometrial
Ovarian
Cervical
Vulval/Vaginal

Answer 7

1. ) Endometrial - bleeding
   - post-menopausal bleeding
   - >55s w/ visible haematuria w/ anaemia OR thrombocytosis OR hyperglycaemia
2. ) Ovarian - multi-system
   - ascites or pelvic/abdominal mass (not uterine fibroids)
   - abdominal distension, change in bowel habits
   - IBS symptoms in over 55s (usually presents earlier)
   - fatigue, weight loss, loss of appetite
3. ) Cervical
   - appearance of cervix consistent w/ cervical cancer
4. ) Vulval/Vaginal
   - vaginal mass
   - vulval bleeding, lump, or ulceration

Question 8

Menopause

Diagnosing Menopause
Additional Menopausal Symptoms
Management
Hormone Replacement Therapy

Answer 8

1. ) Diagnosing Menopause - 45+ w/ symptoms:
   - irregular periods (shorten or lengthen, ↑ blood loss)
   - FSH blood test only if premature (<45) and not on hormonal contraception
2. ) Additional Menopausal Symptoms
   - hot flushes/night sweats, insomnia, ↓libido
   - mood: depression, mood swings
   - MSK: joint and muscle aches and pains
   - urinary/vaginal: dryness, dyspareunia, recurrent UTIs
3. ) Management
   - assess risk of CVD and osteoporosis
   - HRT, anti-depressants, CBT, relaxation techniques
   - review in 3 months then annually
4. ) HRT - most women require only for 2-5 years
   - w/o uterus: oral/transdermal oestrogen only HRT
   - w/ uterus: oral/transdermal combined HRT
   - cyclical combined (first 14 oestrogen only, last 14 combined) for perimenopausal women
   - continous combined for postmenopausal women
   - urogenital symptoms: topical (vaginal) oestrogen
   - risks: VTE, CVD (small), breast cancer

Question 9

Lower Urinary Tract Symptoms (LUTS)

Symptoms
Serious Causes of LUTS
Examinations/Investigations
Urinary Frequency-Volume Chart
Management

Answer 9

1. ) Symptoms
   - storage: polyuria/nocturia, urgency, incontinence
   - voiding: hesitancy, poor flow, terminal dribbling
2. ) Serious Causes of LUTS
   - cancer: enlarged prostate, haematuria, weight loss, low back pain, bone pain,
   - infection: dysuria, pelvic/loin pain, fever
   - sciatica
3. ) Examination/Investigations
   - abdomen: bladder distension, suprapubic dullness
   - external genitalia: phimosis, meatal stenosis
   - DRE - size, consistency, nodules, tenderness
   - International Prostate Symptoms Score: assesses severity of LUTS
   - urine dip, PSA
4. ) Urinary Frequency-Volume Chart - distinguishes:
   - frequency: high frequency w/ normal volume suggests reduced bladder capacity
   - polyuria: >3L in 24 hours, nocturia (waking at night)
   - nocturnal polyuria: >35% of 24hr urine production)
5. ) Management
   - conservative: pelvic floor training, ↓fluid intake, avoid constipation, containment (pads, catheters etc)
   - tamsulosin/doxazosin if IPPS score >8
   - finasteride if enlarge prostate w/ risk of progression
   - can use both if they meet both criteria
   - oxybutynin (anti-muscarinic) if storage symptoms
   - always review at 4-6 weeks, then every 6-12 months

Question 10

Management of Erectile Dysfunction

Referrals
Sildenafil (Viagra)
Lifestyle Advice

Answer 10

1. ) Referrals
   - urology: always had diificulties, trauma history
   - endocrinology - abnormal blood tests
   - cardiology: severe CVD making sex unsafe
   - mental health: psychogenic causes
2. ) Sildenafil (Viagra) - phosphodiesterase 5 inhibitor
   - given regardless of susespected cause
   - they still require sexual stimulation
3. ) Lifestyle Advice
   - lose weight, stop smoking, reduce alcohol, exercise
   - reduce cycling (if >3 hours per week)
   - do not take unliscensed herbal remedies

Question 11

Causes of Erectile Dysfunction

Neurovascular
Anatomical/Structural
Hormonal
Psychogenic
Drugs

Answer 11

1. ) Neurovascular
   - CVD, hypertension, hyperlipidaemia, smoking
   - stroke, MS, Parkinson’s, SC trauma, CNS tumours
   - DM, renal failure, major pelvic/urethral surgery
2. ) Anatomical/Structural
   - penile/prostate cancer, micropenis, phimosis
3. ) Hormonal - endocrine disorders
   - hypogonadism, hyperprolactinaemia, hyperthyroidism
   - Cushing’s disease, hypopituitarism
4. ) Psychogenic
   - generalised: ↓↓arousal, sexual intimacy disorders
   - situational: stress, partner, performance, psychiatric
5. ) Drugs - just drug classes
   - anti-arrhythmics, anti-hypertensives, diuretics (thiazides)
   - anti-depressants, anti-psychotics, recreational drugs
   - antiandrogens, LHRH agonists,
   - corticosteroids, 5-aRi, H2 antagonists,
   - recreational: alcohol, weed, steroids, coke, heroin